Right to Access

To Receive Your Medication Expenditures:Your must fill out the Right to Access and Consent for Release of Protected Health Information Form

POLICY: In the case of a verbal or written request for PHI included in the Pharmacy’s Medical Expense and Accounts Receivable Information, the Pharmacy may (at the discretion of the Pharmacist, Privacy Officer, bookkeeper or person receiving a written or verbal request) release patient specific information limited to as included in it’s then current Medical Expense and/or Accounts Receivable Information directly to the patient or authorized agent of the patient without having the release herein previously completed.

PURPOSE: In any case where the requested information goes beyond the Pharmacy’s then current Medical Expense and/or Accounts Receivable Information or a Pharmacy employee believes the patient’s PHI is best protected by having the release herein completed prior to release of any PHI, this release serves as the documented request for the release of Protected Health Information (PHI) to the patient or authorized agent of the patient as designated below.

A unique copy of this release must be completed for any given 12 month period. The specific time period for which records are being requested (no future dating allowed) is: (TIME PERIOD TO TIME PERIOD) *

Time Period to Time Period(required)

This disclosure is being made for the purpose(s) of: * (required)

How would you like to receive the Release of your PHI? *(required)

Address (Must match requesting person above): *

Line 1

Line 2

City

State

Zip Code

If you want your records faxed, what fax number should we use? *

My Fax Number

I certify the records being requested are my own personal records or I have the patient’s authorization to request these records. I certify the records obtained are done so in good moral character and without malicious intent. You are required to enter a digital signature which will be binding as your actual signature. Your electronic signature below indicates all information provided is true, complete, and correct. By typing my name in the following box, I certify that I have read, fully understand, and accept all terms of the PHI disclosure statement: *

Electronic Signature(required)

Date(required)

Date of Birth of Signer: *(required)

Contact Phone Number *(required)

Your request for information will be completed within 30 days. This form must be completed in its entirety and submitted to Erickson Pharmacy to begin processing information. Failure to submit this form will result in your request not being processed. Thank you for your patience.